Feasibility of Expanding Self-Directed Services to People with Serious Mental Illness. 3.1. Program Elements


Although mental health SDC programs vary in design and staffing, most programs include the following elements (see Figure 1):1, 2

FIGURE 1. Program Elements
Organizational Chart: PROGRAM MANAGER/SUPERVISOR: (a) Oversees coaches; (b) Pairs clients with coaches; (c) Approves clients' spending plans; (d) May approve non-traditional purchases. Leads to Coach, Client, Fiscal Intermediary, and Provider Network. OACH: (a) Supports goal planning, budgeting, and provider selection; (b) Supports preparation of the written spending plan; (c) May be peer specialist provider. Leads to Client. CLIENT: (a) Selects recovery goals and priorities; (b) Selects providers; (c) Creates a written spending plan and allocates budget according to own recovery goals and priorities. Leads to Coach, Fiscal Intermediary, and Provider Network. FISCAL INTERMEDIARY: (a) Processes payments to service provider; (b) May provide sending reports to Program Manager. Leads to Provider Network. PROVIDER NETWORK: (a) With program, providers agree to rate a payment and billing/payment process; (b) Providers consent to client-centered decision making; (c) Providers provide program their credentialing information. Leads to Program Manager/Supervisor, and Client.

Recovery Plans

Client participants with assistance from coaches (see description, below) create a "recovery plan," a detailed statement of personal recovery goals and corresponding action items. Recovery goals may be broad ranging across domains such as employment, education and training, physical and behavioral health, housing, social interaction, and hobbies.


Client participants with assistance from coaches (description below) create a personalized plan for spending on both traditional and non-traditional products and services, where traditional services are usually defined as those services covered by Medicaid. The total budget available to each individual is determined by the SDC program's administrators, and sometimes varies across individual participants depending on their expected needs or other factors. Budget amounts are specified in the spending plan for each of the services and products included in a consumer's "recovery plan," a detailed statement of recovery goals and corresponding action items. In most programs, program managers or supervisors (description below) are responsible for approving these spending plans.


Coaches assist SDC participants in developing their "recovery plan," support the budgeting process, may offer advice on spending priorities, and serve as a mentor and resource. Coaches are variously termed recovery coach, life coach, support broker, support specialist, and peer-specialist. Coaches receive training in self-directed planning and recovery oriented care. Some programs hire "peers" (i.e., persons who themselves are in recovery and who embody the hope for recovery) into paid positions as SDC coaches, whereas other programs hire professional case managers who have received training in the SDC approach.

Program Manager/Supervisor

The program manager or supervisor is responsible for employing and supervising coaches, pairing SDC participants with coaches, ensuring that coaches receive appropriate training, ensuring regulatory compliance (e.g., with state mental health and Medicaid regulations), approving budgets and individual participants spending plans, and other executive functions of SDC program administration. In some programs, the program manager is responsible for approving participants' purchases of non-traditional products and services, in accordance with the SDC program's purchasing policies.

Fiscal Intermediary

A fiscal (or financial) intermediary in SDC is an agent that processes payments to service providers and helps manage accounting and other fiscal responsibilities, such as handling, managing, and accounting for funds in individual budgets, preparing payroll taxes (for personal assistance services employees) and maintaining required tax records.13 A SDC program may also contract with a fiscal intermediary to handle other tasks, such as providing standardized reports to the SDC program and its participants regarding participants' services utilization and expenditures. A fiscal intermediary could also be responsible for helping ensure that participants do not exceed their budgets, for example, by providing information. The fiscal intermediary also has an obligation to ensure that all required agreements between participants and providers are in place before making payment and may perform support functions such as checking provider qualifications and conducting reference and background checks. The fiscal intermediary does not contract directly for any services and does not serve as an employer of service providers.

In mental health SDC programs, various arrangements have been made for fiscal intermediary services. In some programs, a not-for-profit community service organization has served as fiscal intermediary under a contract to the state mental health authority. In other programs, a local core serve agency, a branch of the state mental health authority, fulfills this role. In other programs, some of the functions of the fiscal intermediary are contracted out to a managed behavioral health care organization while the program administrator fulfills others. Many non-mental healthSDC programs contract with a "fiscal management entity," an independent organization that specializes in providing fiscal intermediary services to SDC programs, though this arrangement has rarely been used in mental health SDC.

Provider Network

Most SDC programs establish a provider network and do not reimburse expenses for encounters with other (non-network) providers. However, most programs accept into the network any willing provider who agrees to the SDC program's rules and accepts the SDC approach. Often a program will also negotiate with the provider a specified level of reimbursement for encounters with SDC participants. Some SDC programs also have a vetting process that includes verification of the provider's credentials and standing in the community.

Mental health SDC participants typically have not directly hired employees, such as personal care attendants frequently hired by persons with primary physical disabilities. By contrast, the employer authority (i.e., the option offered to program participants to serve as the legal employer of a service provider) is a critical feature of Cash and Counseling and other consumer-directed programs for persons with physical disabilities. For persons with physical disabilities, in-home support services and transportation services are essential in order to be able to live independently in the community. The authority to hire and fire personal assistance services providers gives participants the flexibility to select those service providers that are most likely to meet their requirements. However, in most mental health SDC programs, providers have maintained their own employment, and have been paid on a fee-for-service basis. How the employer authority might work in mental health SDC programs should be considered, as this authority would seem to be an important component of a recovery oriented approach, at least for some SDC participants.

Information Resources

Worksheets, websites, and educational materials are offered to support planning and independence from formal services. Coaches maintain a working knowledge of these resources and help direct participants to relevant ones.

Implementing and Monitoring the Recovery Plan

The participant, with the support of the life coach as necessary, monitors the recovery plan and its implementation, the spending plan, and the budget on an ongoing basis. Participants may change services, providers and supports as needed within the constraints of their individual budgets.

Consumer Oversight

Current and former SDC participants also often have key roles in the management, oversight, and administration of SDC programs. Their participation serves, in part, to ensure that the program continues to adhere to the principles of autonomy and self-direction. Consumers also may advocate for continued program funding, nominate providers to the network, and design training materials for coaches. In some SDC programs, consumers also have input into the development of purchasing policies and procedures.

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